Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.07.034
Tullio Ghi PhD, Veronica Falcone MD, Andrea Dall’Asta PhD
{"title":"Primum non nocere: why to use ultrasound to predict when instrumental vaginal delivery is feasible","authors":"Tullio Ghi PhD, Veronica Falcone MD, Andrea Dall’Asta PhD","doi":"10.1016/j.ajog.2025.07.034","DOIUrl":"10.1016/j.ajog.2025.07.034","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Pages e71-e72"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144720095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.06.059
Aaron W. Roberts MD, Vahed Maroufy PhD, Ashley Salazar DNP, Edgar Hernandez-Andrade MD, PhD, Suneet P. Chauhan MD, Hon DSc, Patrick Dicker MA, MSc, PhD, CStat
{"title":"The origin of Hadlock's table: a reply","authors":"Aaron W. Roberts MD, Vahed Maroufy PhD, Ashley Salazar DNP, Edgar Hernandez-Andrade MD, PhD, Suneet P. Chauhan MD, Hon DSc, Patrick Dicker MA, MSc, PhD, CStat","doi":"10.1016/j.ajog.2025.06.059","DOIUrl":"10.1016/j.ajog.2025.06.059","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Pages e64-e67"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144547874","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.06.038
Margaret E. Cruikshank MD, Anne Hammer MD, PhD, IPVS HPV Latency Working Group and the IPVS Policy Committee
{"title":"Updating the basic biology of human papillomavirus infection in the early natural history of cervical cancer","authors":"Margaret E. Cruikshank MD, Anne Hammer MD, PhD, IPVS HPV Latency Working Group and the IPVS Policy Committee","doi":"10.1016/j.ajog.2025.06.038","DOIUrl":"10.1016/j.ajog.2025.06.038","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Page e58"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144487920","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.06.049
Chelsea J. Messinger MD, PhD , Sonia Hernández-Díaz MD, DrPH , Albert Hofman MD, PhD , Natalie Sadlak MD , Jon Einarsson MD, PhD, MPH , Thomas F. McElrath MD, PhD
<div><h3>Background</h3><div>The 2020 Multicentre Abdominal vs Vaginal Randomised Intervention of Cerclage trial found that transabdominal cerclage placed via open laparotomy reduces the risk of spontaneous preterm birth before 32 weeks relative to transvaginal cerclage in a very high-risk obstetric population. It is not known whether the results of the trial generalize to obstetric populations with fewer risk factors, on average, for recurrent spontaneous preterm birth, or to patients without history of failed transvaginal cerclage (an inclusion criterium in the trial).</div></div><div><h3>Objective</h3><div>1) To estimate the effect of transabdominal cerclage vs transvaginal cerclage on early preterm delivery (<34 weeks) among patients with history of cervical insufficiency at a quaternary care center; 2) to estimate the effect within a subgroup of patients without history of failed transvaginal cerclage; and 3) to describe associated complications of placement and delivery and neonatal outcomes.</div></div><div><h3>Study design</h3><div>We identified a cohort of adult singleton pregnancies who received history-indicated cerclage at a quaternary care center in the United States. The cohort consisted of patients with a history of <span><math><mrow><mo>≥</mo></mrow></math></span>1 spontaneous deliveries (birth or fetal loss) <28 weeks and patients with a history of failed transvaginal cerclage, defined as <span><math><mrow><mo>≥</mo></mrow></math></span>1 spontaneous preterm deliveries <34 weeks with cervical cerclage in situ. All eligible patients who received transabdominal cerclage were compared to a sample of eligible patients who received transvaginal cerclage. We performed survival analysis with inverse probability weights to adjust for potential sources of bias. Effects were estimated as risk difference, risk ratio, and 95% confidence intervals. Subgroup analyses were performed among patients without a history of failed transvaginal cerclage. The risks of surgical, delivery, and neonatal outcomes were described.</div></div><div><h3>Results</h3><div>One hundred eighty-eight patients were included, of whom 87 received transabdominal cerclage (99% laparoscopic) and 101 received transvaginal cerclage. Twenty-six patients (30%) with transabdominal cerclage had no history of failed transvaginal cerclage, the majority of whom had additional clinical reasons why transabdominal cerclage was offered. After adjusting for confounding, the adjusted risk of early preterm delivery was 5.5% in the transabdominal group (95% confidence interval, 2.0%, 9.4%) and 18.7% in the transvaginal group (95% confidence interval, 6.8%, 31.4%), risk difference = −13.1% (95% confidence interval, −26.6%, −0.5%), and risk ratio = 0.30 (95% confidence interval, 0.10, 0.94). Among patients without history of failed transvaginal cerclage (N = 104 total, N = 26 in transabdominal group), the risk difference was −12.6% (−21.6%, −4.1%). Risks of placement and delivery co
{"title":"Effect of transabdominal versus transvaginal cerclage on preterm birth and neonatal outcomes among patients with a history of cervical insufficiency","authors":"Chelsea J. Messinger MD, PhD , Sonia Hernández-Díaz MD, DrPH , Albert Hofman MD, PhD , Natalie Sadlak MD , Jon Einarsson MD, PhD, MPH , Thomas F. McElrath MD, PhD","doi":"10.1016/j.ajog.2025.06.049","DOIUrl":"10.1016/j.ajog.2025.06.049","url":null,"abstract":"<div><h3>Background</h3><div>The 2020 Multicentre Abdominal vs Vaginal Randomised Intervention of Cerclage trial found that transabdominal cerclage placed via open laparotomy reduces the risk of spontaneous preterm birth before 32 weeks relative to transvaginal cerclage in a very high-risk obstetric population. It is not known whether the results of the trial generalize to obstetric populations with fewer risk factors, on average, for recurrent spontaneous preterm birth, or to patients without history of failed transvaginal cerclage (an inclusion criterium in the trial).</div></div><div><h3>Objective</h3><div>1) To estimate the effect of transabdominal cerclage vs transvaginal cerclage on early preterm delivery (<34 weeks) among patients with history of cervical insufficiency at a quaternary care center; 2) to estimate the effect within a subgroup of patients without history of failed transvaginal cerclage; and 3) to describe associated complications of placement and delivery and neonatal outcomes.</div></div><div><h3>Study design</h3><div>We identified a cohort of adult singleton pregnancies who received history-indicated cerclage at a quaternary care center in the United States. The cohort consisted of patients with a history of <span><math><mrow><mo>≥</mo></mrow></math></span>1 spontaneous deliveries (birth or fetal loss) <28 weeks and patients with a history of failed transvaginal cerclage, defined as <span><math><mrow><mo>≥</mo></mrow></math></span>1 spontaneous preterm deliveries <34 weeks with cervical cerclage in situ. All eligible patients who received transabdominal cerclage were compared to a sample of eligible patients who received transvaginal cerclage. We performed survival analysis with inverse probability weights to adjust for potential sources of bias. Effects were estimated as risk difference, risk ratio, and 95% confidence intervals. Subgroup analyses were performed among patients without a history of failed transvaginal cerclage. The risks of surgical, delivery, and neonatal outcomes were described.</div></div><div><h3>Results</h3><div>One hundred eighty-eight patients were included, of whom 87 received transabdominal cerclage (99% laparoscopic) and 101 received transvaginal cerclage. Twenty-six patients (30%) with transabdominal cerclage had no history of failed transvaginal cerclage, the majority of whom had additional clinical reasons why transabdominal cerclage was offered. After adjusting for confounding, the adjusted risk of early preterm delivery was 5.5% in the transabdominal group (95% confidence interval, 2.0%, 9.4%) and 18.7% in the transvaginal group (95% confidence interval, 6.8%, 31.4%), risk difference = −13.1% (95% confidence interval, −26.6%, −0.5%), and risk ratio = 0.30 (95% confidence interval, 0.10, 0.94). Among patients without history of failed transvaginal cerclage (N = 104 total, N = 26 in transabdominal group), the risk difference was −12.6% (−21.6%, −4.1%). Risks of placement and delivery co","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Pages 480-506"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144615829","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.05.047
Jisen Zhao PhD, Dong Guo PhD
{"title":"Addressing methodologic gaps in doula care research: recommendations for enhancing rigor and equity in maternal health studies","authors":"Jisen Zhao PhD, Dong Guo PhD","doi":"10.1016/j.ajog.2025.05.047","DOIUrl":"10.1016/j.ajog.2025.05.047","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Page e54"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144245739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.10.009
Roni Nitecki Wilke MD, MPH, Nuria Agusti MD, Nuria Agusti MD, Chi-Fang Wu PhD, MD, Maria D. Iniesta MD, PhD, William B. Manning MD, David Viveros-Carreno MD, Allison W. Kurian MD, MSc, J. Alejandro Rauh-Hain MD, MPH, Alexander Melamed MD, MPH
{"title":"Association between germline BRCA1 pathogenic variants and uterine serous carcinoma among women with breast cancer: a population-based analysis","authors":"Roni Nitecki Wilke MD, MPH, Nuria Agusti MD, Nuria Agusti MD, Chi-Fang Wu PhD, MD, Maria D. Iniesta MD, PhD, William B. Manning MD, David Viveros-Carreno MD, Allison W. Kurian MD, MSc, J. Alejandro Rauh-Hain MD, MPH, Alexander Melamed MD, MPH","doi":"10.1016/j.ajog.2025.10.009","DOIUrl":"10.1016/j.ajog.2025.10.009","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Pages e37-e41"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145314641","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.06.058
Jessica L. Gleason PhD, MPH, Zhen Chen PhD, Katherine L. Grantz MD, MS
{"title":"A comment on revisiting Hadlock","authors":"Jessica L. Gleason PhD, MPH, Zhen Chen PhD, Katherine L. Grantz MD, MS","doi":"10.1016/j.ajog.2025.06.058","DOIUrl":"10.1016/j.ajog.2025.06.058","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Pages e59-e63"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144551726","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.09.022
Marcus Cabrera-Dandy MBChB (Hons) , Maria Regina Torloni MD, PhD , Mario Merialdi MD, PhD, MPH , Elena Greco PhD , Stamatina Iliodromiti PhD
Objective
To synthesize evidence on the effectiveness of different instruments for assisted vaginal birth and to assess the prevalence of maternal and neonatal adverse outcomes associated with assisted vaginal birth and second-stage cesarean section.
Data Sources
A comprehensive search was conducted in Cochrane, Embase, and MEDLINE to identify randomized controlled trials and cross-sectional and cohort studies published between January 2001 and December 2023.
Study Eligibility Criteria
Studies published in English, Spanish, French, or Italian with >30 participants, conducted in any type of healthcare facility, and reporting operative procedures in the second stage of labor were eligible if they included at least one outcome of interest for women undergoing assisted vaginal birth and/or second-stage cesarean section.
Study Appraisal and Synthesis Methods
Two independent reviewers conducted study selection, data extraction, and quality assessment. Meta-analyses of proportions were performed using random-effects models, and heterogeneity was assessed using the I2 statistic.
Results
A total of 241 studies, involving 751,242 participants, were included, of which 231 were observational and 10 randomized controlled trials. Prevalence estimates for assisted vaginal birth failure and adverse outcomes varied widely. Vacuum extraction had a significantly higher failure rate than forceps (7.60% vs 3.26%, P<.01), but a lower prevalence of obstetric anal sphincter injury (4.73% vs 7.99%, P<.01). Spatula use was associated with a lower prevalence of neonatal cephalohematoma compared to vacuum extraction (0.73% vs 5.45%, P<.01) and forceps (0.73% vs 3.54%, P<.01), but a higher prevalence of postpartum hemorrhage compared to vacuum extraction (10.77% vs 5.46%, P<.0001). Compared to assisted vaginal birth, second-stage cesarean section was associated with significantly higher rates of neonatal intensive care unit admission (17.18% vs 6.64% forceps, 6.07% vacuum extraction, P<.001), low Apgar scores (6.01% vs 2.43% forceps, 2.05% vacuum extraction, P<.01), skull fractures (1.54% vs 0.27% for both, P<.05), and neonatal death (1.95% vs 0.31% for both, P<.01).
Conclusion
Contemporary data reveal wide variability in the prevalence of failed assisted vaginal birth and adverse maternal and neonatal outcomes following operative delivery in the second stage of labor. While assisted vaginal birth carries specific risks, it may offer advantages over emergency second-stage cesarean section, particularly regarding neonatal outcomes.
目的综合不同辅助阴道分娩器械的有效性，评估辅助阴道分娩与二期剖宫产（SCS）相关的孕产妇和新生儿不良结局的发生率。资料来源在Cochrane、Embase和MEDLINE中进行了全面检索，以确定2001年1月至2023年12月间发表的随机对照试验、横断面和队列研究。研究资格标准：在任何类型的医疗机构中，以英语、西班牙语、法语或意大利语发表的、有bb30名参与者的研究，报告了分娩第二阶段的手术过程，如果研究至少包括一个对接受AVB和/或SCS的妇女感兴趣的结局，则符合条件。研究评价和综合方法由两名独立的审稿人进行研究选择、数据提取和质量评估。采用随机效应模型对比例进行meta分析，采用I2统计量评估异质性。结果共纳入241项研究，涉及751,242名受试者，其中观察性试验231项，随机对照试验10项。AVB失败和不良后果的患病率估计差异很大。真空拔管失败率明显高于产钳（7.60% vs. 3.26%, p<0.01），但产科肛门括约肌损伤发生率较产钳低（4.73% vs. 7.99%, p<0.01）。与VE相比，使用抹刀的新生儿头血肿患病率较低（0.73% vs. 5.45%, p<0.01），使用产钳的新生儿头血肿患病率较低（0.73% vs. 3.54%, p<0.01），但与VE相比，使用抹刀的产后出血患病率较高（10.77% vs. 5.46%, p<0.0001）。与AVB相比，SCS与NICU入院率（17.18% vs. 6.64%, VE 6.07%, p<0.001）、低Apgar评分（6.01% vs. 2.43%, VE 2.05%, p<0.01）、颅骨骨折（1.54% vs. 0.27%, p<0.05）和新生儿死亡（1.95% vs. 0.31%, p<0.01）相关。结论：当代数据显示，在第二产程手术分娩后，AVB失败的患病率和不良的孕产妇和新生儿结局存在很大的差异。虽然AVB具有特定的风险，但它可能比紧急SCS更具优势，特别是在新生儿结局方面。
{"title":"Effectiveness and safety of assisted vaginal birth and second-stage cesarean section: a systematic review and meta-analysis of real-world contemporary data","authors":"Marcus Cabrera-Dandy MBChB (Hons) , Maria Regina Torloni MD, PhD , Mario Merialdi MD, PhD, MPH , Elena Greco PhD , Stamatina Iliodromiti PhD","doi":"10.1016/j.ajog.2025.09.022","DOIUrl":"10.1016/j.ajog.2025.09.022","url":null,"abstract":"<div><h3>Objective</h3><div>To synthesize evidence on the effectiveness of different instruments for assisted vaginal birth and to assess the prevalence of maternal and neonatal adverse outcomes associated with assisted vaginal birth and second-stage cesarean section.</div></div><div><h3>Data Sources</h3><div>A comprehensive search was conducted in Cochrane, Embase, and MEDLINE to identify randomized controlled trials and cross-sectional and cohort studies published between January 2001 and December 2023.</div></div><div><h3>Study Eligibility Criteria</h3><div>Studies published in English, Spanish, French, or Italian with >30 participants, conducted in any type of healthcare facility, and reporting operative procedures in the second stage of labor were eligible if they included at least one outcome of interest for women undergoing assisted vaginal birth and/or second-stage cesarean section.</div></div><div><h3>Study Appraisal and Synthesis Methods</h3><div>Two independent reviewers conducted study selection, data extraction, and quality assessment. Meta-analyses of proportions were performed using random-effects models, and heterogeneity was assessed using the I<sup>2</sup> statistic.</div></div><div><h3>Results</h3><div>A total of 241 studies, involving 751,242 participants, were included, of which 231 were observational and 10 randomized controlled trials. Prevalence estimates for assisted vaginal birth failure and adverse outcomes varied widely. Vacuum extraction had a significantly higher failure rate than forceps (7.60% vs 3.26%, <em>P</em><.01), but a lower prevalence of obstetric anal sphincter injury (4.73% vs 7.99%, <em>P</em><.01). Spatula use was associated with a lower prevalence of neonatal cephalohematoma compared to vacuum extraction (0.73% vs 5.45%, <em>P</em><.01) and forceps (0.73% vs 3.54%, <em>P</em><.01), but a higher prevalence of postpartum hemorrhage compared to vacuum extraction (10.77% vs 5.46%, <em>P</em><.0001). Compared to assisted vaginal birth, second-stage cesarean section was associated with significantly higher rates of neonatal intensive care unit admission (17.18% vs 6.64% forceps, 6.07% vacuum extraction, <em>P</em><.001), low Apgar scores (6.01% vs 2.43% forceps, 2.05% vacuum extraction, <em>P</em><.01), skull fractures (1.54% vs 0.27% for both, <em>P</em><.05), and neonatal death (1.95% vs 0.31% for both, <em>P</em><.01).</div></div><div><h3>Conclusion</h3><div>Contemporary data reveal wide variability in the prevalence of failed assisted vaginal birth and adverse maternal and neonatal outcomes following operative delivery in the second stage of labor. While assisted vaginal birth carries specific risks, it may offer advantages over emergency second-stage cesarean section, particularly regarding neonatal outcomes.</div></div>","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Pages 310-320"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145059191","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.ajog.2025.09.011
Lirong Yan MM , Chenfeng Zhu MD , Wei Xia MD , Yang Wang MM , Chuqing He MD , Qian Zhu MD , Judith Anna Huirne MD , Ben W. Mol PhD , Jian Zhang MD
<div><h3>Background</h3><div>Previous findings demonstrated that both the 52-mg levonorgestrel intrauterine system and hysteroscopic niche resection significantly reduced niche-related postmenstrual spotting, with more than 70% of patients achieving ≥50% reduction at 6 months and levonorgestrel intrauterine system showing superior efficacy beyond 9 months.</div></div><div><h3>Objective</h3><div>This study evaluates the long-term effectiveness of both treatments in reducing niche-related postmenstrual spotting over 36 months.</div></div><div><h3>Study design</h3><div>This 3-year follow-up stems from a single-center randomized trial. Women experiencing postmenstrual spotting after cesarean delivery, with magnetic resonance imaging–confirmed niche depth ≥2.0 mm and residual myometrium ≥2.2 mm, and without plans to conceive within 1 year, were randomized to receive either the 52-mg levonorgestrel intrauterine system or hysteroscopic niche resection. Main outcome of this long-term follow-up was the proportion of women achieving ≥50% reduction in spotting from baseline at 36 months. Secondary outcomes, including menstrual patterns, spotting discomfort, chronic pelvic pain, and satisfaction with treatment, were assessed at 18, 24, 30, and 36 months.</div></div><div><h3>Results</h3><div>A total of 208 women were randomized (104 in each group), with 93 (89.4%) in the levonorgestrel intrauterine system group and 89 (85.6%) in the hysteroscopic niche resection group completing the 3-year follow-up. At 36 months, 98.9% of women in the levonorgestrel intrauterine system group and 51.7% in the hysteroscopic group achieved a 50% reduction in spotting (relative risk, 1.91 [95% confidence interval, 1.56–2.34]; <em>P</em><.001). Spotting decreased progressively over time in the levonorgestrel intrauterine system group through 36 months (P<sub>trend</sub>=0.001), whereas the hysteroscopic group showed reduction only until 24 months (<em>P</em>=.007), followed by a slight increase. A significant time-treatment interaction was observed (<em>P</em>=.007), with levonorgestrel intrauterine system demonstrating superior spotting reduction from 24 months onward. Additionally, the levonorgestrel intrauterine system group had fewer postmenstrual spotting days, total bleeding days (<em>P</em><.001), and less pelvic pain (<em>P</em><.010) from 6 months onward, with the difference widening over time. During the follow-up, 20 women in the levonorgestrel intrauterine system group reported hormone-related side effects, and 2 experienced partial expulsions. In the hysteroscopic group, 5 pregnancies were reported (3 unintended and 2 planned).</div></div><div><h3>Conclusion</h3><div>Over 36 months, the 52-mg levonorgestrel intrauterine system was superior to hysteroscopic niche resection for reducing postmenstrual spotting, pelvic pain, and discomfort, while also offering contraceptive benefits in women with symptomatic niche. We recommend levonorgestrel intrauterine system
{"title":"Levonorgestrel intrauterine system vs hysteroscopic niche resection for postmenstrual spotting: a 3-year randomized trial follow-up","authors":"Lirong Yan MM , Chenfeng Zhu MD , Wei Xia MD , Yang Wang MM , Chuqing He MD , Qian Zhu MD , Judith Anna Huirne MD , Ben W. Mol PhD , Jian Zhang MD","doi":"10.1016/j.ajog.2025.09.011","DOIUrl":"10.1016/j.ajog.2025.09.011","url":null,"abstract":"<div><h3>Background</h3><div>Previous findings demonstrated that both the 52-mg levonorgestrel intrauterine system and hysteroscopic niche resection significantly reduced niche-related postmenstrual spotting, with more than 70% of patients achieving ≥50% reduction at 6 months and levonorgestrel intrauterine system showing superior efficacy beyond 9 months.</div></div><div><h3>Objective</h3><div>This study evaluates the long-term effectiveness of both treatments in reducing niche-related postmenstrual spotting over 36 months.</div></div><div><h3>Study design</h3><div>This 3-year follow-up stems from a single-center randomized trial. Women experiencing postmenstrual spotting after cesarean delivery, with magnetic resonance imaging–confirmed niche depth ≥2.0 mm and residual myometrium ≥2.2 mm, and without plans to conceive within 1 year, were randomized to receive either the 52-mg levonorgestrel intrauterine system or hysteroscopic niche resection. Main outcome of this long-term follow-up was the proportion of women achieving ≥50% reduction in spotting from baseline at 36 months. Secondary outcomes, including menstrual patterns, spotting discomfort, chronic pelvic pain, and satisfaction with treatment, were assessed at 18, 24, 30, and 36 months.</div></div><div><h3>Results</h3><div>A total of 208 women were randomized (104 in each group), with 93 (89.4%) in the levonorgestrel intrauterine system group and 89 (85.6%) in the hysteroscopic niche resection group completing the 3-year follow-up. At 36 months, 98.9% of women in the levonorgestrel intrauterine system group and 51.7% in the hysteroscopic group achieved a 50% reduction in spotting (relative risk, 1.91 [95% confidence interval, 1.56–2.34]; <em>P</em><.001). Spotting decreased progressively over time in the levonorgestrel intrauterine system group through 36 months (P<sub>trend</sub>=0.001), whereas the hysteroscopic group showed reduction only until 24 months (<em>P</em>=.007), followed by a slight increase. A significant time-treatment interaction was observed (<em>P</em>=.007), with levonorgestrel intrauterine system demonstrating superior spotting reduction from 24 months onward. Additionally, the levonorgestrel intrauterine system group had fewer postmenstrual spotting days, total bleeding days (<em>P</em><.001), and less pelvic pain (<em>P</em><.010) from 6 months onward, with the difference widening over time. During the follow-up, 20 women in the levonorgestrel intrauterine system group reported hormone-related side effects, and 2 experienced partial expulsions. In the hysteroscopic group, 5 pregnancies were reported (3 unintended and 2 planned).</div></div><div><h3>Conclusion</h3><div>Over 36 months, the 52-mg levonorgestrel intrauterine system was superior to hysteroscopic niche resection for reducing postmenstrual spotting, pelvic pain, and discomfort, while also offering contraceptive benefits in women with symptomatic niche. We recommend levonorgestrel intrauterine system","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"234 2","pages":"Pages 390-399"},"PeriodicalIF":8.4,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145056651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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